The "chronically-critically ill" are a population that has been recognized as a distinct group only for the past decade (Daly et al, 1991; Girard & Raffin, 1985). These patients experience a prolonged period of critical illness, due either to complications of their primary illness or exacerbation of pre-existing chronic diseases and have also been categorized as "long-term ventilator patients" because of the universal requirement for lengthy periods of mechanical ventilation. Previous research has documented enormous yearly costs, estimated at $18.6 billion nationally (Goins, et al, 1991). Despite this investment, in-patient mortality rates remain at 30-50% (Daly et al, 1991; Cohen & Booth, 1994). While we have previously demonstrated that the availability of a "Special Care Unit," for this population, can reduce in-patient costs and improve clinical outcomes (Douglas, Daly et al, 1996; Rudy, Daly, Douglas et al, 1995), until recently there has been no attention paid to continuing care needs of patients who are able to wean from the ventilator and be discharged from the hospital. There is now sufficient evidence that, even after discharge, chronically critically ill patients continue to require intensive resources but experience very poor outcomes The current project designed to extend those features of the Special Care Unit that were shown to be effective in reducing costs and improving outcomes during hospitalization to the first two months of the post- discharge period. It is the first study to test an out-patient intervention for this segment of the ICU population. The intervention will consist of a disease-management program, implemented by a team of Advanced Practice Nurses (APN), pulmonologist, and geriatrician. The following research questions will be investigated: (1)Are there differences between chronically critically ill patients who participate in a disease management program and those who do not in relative resource use in the first 2 months post-discharge? (2) Are there differences between chronically critically ill patients who participate in a disease management program and those who do not in quality of life, mortality, and rehospitalization in the first 2 months post-discharge? (3) Are there differences between chronically critically ill patients who participate in a disease management program and those who do not in satisfaction with care in the first two months post-discharge? (4) Are there differences between family members of chronically critically ill patients who participate in a disease management program and family members of those who do not in care-giving burden and depression?